THE NEW INDIA ASSURANCE CO. LTD.

,
Regd. & Head Office: 87, M.G. Road, Fort, Mumbai- 400 001.
Med - 02
PROPOSAL FORM FOR FAMILY FLOATER MEDICLAIM POLICY

Please read the prospectus before filling up this form.

A) The Company shall not be on risk until the proposal has been accepted by the Company and
communications of acceptance has been given to the proposer in writing on full payment of premium.

B) For persons above 45 years of age or persons below 45 years of age, having adverse medical history
declared in the proposal form will have to undergo, pre-acceptance health check up at a designated
hospital/nursing home. The Divisional Office/Branch Office in the name of hospital/Nursing home will give a
referral slip for conducting the pre-acceptance health check up. The details of the check up to be done are
available with the Divisional Office/Branch Office.

C) If other family members residing with proposer i.e. spouse, eligible dependent children and dependent
parents and dependent parents in law are required to be covered, complete details of each person should be
furnished. Two Stamp size photograph of each person are to be submitted, one of which is to be affixed on the
proposal.
D) Fresh proposal form is required along with pre acceptance medical check up as mentioned in item (B)
Downloaded from www.insureatclick.com-Broker : Loyal Insurance Brokers Ltd.

above, irrespective of age, when there is break in insurance cover or when there is request for enhancement in
the sum insured.

E) Non-disclosure of facts material to the assessment of the risk, providing misleading information,
fraud or non-co-operation by the insured will nullify the cover under the policy.

1. NAME OF PROPOSER : Mr/Mrs.____________________________________

2. RESIDENTIAL
ADDRESS:_______________________________________________________

Tel.No:__________________Fax No. E-Mail:____

3. Occupation: (please Tick)

 Professional/Administrative/Managerial
 Business /Traders
 Clerical, Supervisory and related workers
 Hospitality and Support Workers
 Production Workers, Skilled and non-Agricultural Labourers
 Farmers and Agricultural Workers
 Police/Para Military/Defence
 Housewives
 Retired Persons
 Students – School and College
 Any Other

Fam-Fltr-Med-Pro-Form 1
 4. Average Monthly Income Rs._______________ Income Tax PAN No:__________

5. NAME, ADDRESS & TEL.NO: OF FAMILY PHYSICIAN_____________________________

_______________________________________________________________________
QUALIFICATION:____________________ REGN .NO: _________________

6. Are you a member of Recognized Health Club/Gymnasium:

If yes, then submit proof of your membership __________________________

7. Are you at present or have you been at any other time in the past covered under any other Insurance (PA,
Cancer Insurance, Hospitalization Insurance or other Medical Insurance). If so, give particulars of:

Sr. Content Details

No.
Name of Insurer
Insurance Scheme
Policy No.
Period of cover
Claim Amt. Recd./receivable
Downloaded from www.insureatclick.com-Broker : Loyal Insurance Brokers Ltd.

8.Any proposal for this Insurance or any other similar insurance refused or cancelled or higher premium
charged. If so, give details:

9.DETAILS OF PERSONS TO BE INSURED:

Sr. Name of all the Date of Age Sex Relation Sum History of Signature
No persons Birth (M/F) with the Insured (Pl s. Tick)
: Proposer selected Diab Hyper
etes tension

1
2
3
4
5
6.

10. MEDICAL HISTORY: Please answer the following questions with Yes or No (A dash is not sufficient
and give full details in respect of all the persons to be insured)

Fam-Fltr-Med-Pro-Form 2
 1) Are all the members proposed for insurance in good health and free from physical and Mental disease or
infirmity? If no, give details of the illnesses/ diseases for each member. Select the illness/conditions from the
table given below:

Sr. Name of the Person Nature of illness/pre-existing diseases (*)

No.

*Table for selecting Pre-Existing Disease (PED)

Ischaemic Heart Disease Hypertension Diabetes Mellitus

Spinal or Vertebral Disorders Cataract Breathing Disorders
Uterine Bleeding Arthritis and Joint disorders Gastritis and Duodenitis
Downloaded from www.insureatclick.com-Broker : Loyal Insurance Brokers Ltd.

Kidney disorders Headache Syndromes Hernia

Stroke and T.I.A. Thyroid and Other Hormonal E.N.T. Disorders
Disorders
Cholelithiasis Any Malignancy Hemorrhoids

Enlargement of Prostate (BPH, Any Other (Please specify)

enlargement of prostate)

2) Has any of the persons proposed for insurance has suffered from any illness/disease or had an accident in
the past? If so, give details as under:

Name of Nature of Date on which first First treatment Name of attending

the illness/disease/injury & treatment taken completed/is medical
person treatment received continuing practitioner/surgeon
with his address &
tel. Nos.

Note: This information should be given for any of the persons proposed for insurance, if he/she had suffered
from any illness/disease injury, please give details separately.

Fam-Fltr-Med-Pro-Form 3
 3) Are there any additional facts affecting the proposed
Insurance, which should be disclosed to insurers? If yes,
then give details below:

4) Please give details of any knowledge or any positive

existence or presence of any ailment, sickness or
injury, which may require medical attention? If yes,
then give details below:

5) Where do you wish to take treatment? : Zone I (Mumbai)

Zone II (Delhi/Bangalore)
Zone III (Rest of India)

6) Name of the Assignee- Relationship

7) Period of Insurance: From____________ To _______________

8) Declaration: I declare that the persons proposed for insurance are my family members and they are not engaged in
high risk occupation. I also declare that none of them suffer from any pre-existing conditions and that I have given
Downloaded from www.insureatclick.com-Broker : Loyal Insurance Brokers Ltd.

explicit information of such sickness/disease/injury sustained in the above columns where the information has been
sought. I further declare that the above statements in respect of myself and my family members, are true and complete. I
consent and authorize the insurers to seek medical information from any Hospital/Medical Practitioner who has at any
time attended me or my family members or may attend concerning any disease or illness which affects my or my family
members, physical or mental health. I agree that this proposal shall form the basis of the contract should the insurance be
affected. If after the insurance is affected, it is found that the statements, answers or particulars stated in the Proposal
form and its Questionnaires are incorrect or untrue in any respect, the Insurance Company shall incur no liability under
this insurance.

Photographs of Insured Persons:

Propo
ser 1 2 3 4 5 6

Signature of the Proposer:__________________Date: __________/_________/_________

DD MM YY
Place:______________

Fam-Fltr-Med-Pro-Form 4
 Section 41 of Insurance Act, 1938
Prohibition of Rebates

1) No person shall allow or offer to allow either directly or indirectly as an inducement of any person to take
out or renew or continue an insurance in respect of any kind of risk relating to lives or property in India any
rebate of the whole or part of the commission payable or any rebate of the premium shown on the policy nor
shall any person taking out or renewing or continuing a policy except any rebate except such rebate as may be
allowed in accordance with the prospectus or tables of the insurer.

2) Any person making default in complying with the provisions of this Section shall be punishable with fine,
which may extend to five hundred rupees.

FOR OFFICE USE ONLY:

Sr. Name of Date of Sex Relation Occupa S.I. CB Premium Loading Loading for
Downloaded from www.insureatclick.com-Broker : Loyal Insurance Brokers Ltd.

No insured Birth M/F -tion (Rs.) % for high claim

. person /Age diabetes ratio
and
hyperten
sion
1
2
3
4
5
6
Remarks of Underwriter: Total:

Loyalty Discount

Family Discount 10%

Service Tax

Gross Total

Fam-Fltr-Med-Pro-Form 5